title: The use of the Berlin definition for acute respiratory distress syndrome during infancy and early childhood: multicenter evaluation and expert consensus.
abstract: OBJECTIVE
  A new acute respiratory distress syndrome (ARDS) definition has been recently issued: the so-called Berlin definition (BD) has some characteristics that could make it suitable for pediatrics. The European Society for Pediatric Neonatal Intensive Care (ESPNIC) Respiratory Section started a project to evaluate BD validity in early childhood. A secondary aim was reaching a consensus on clinical tools (risk factors list and illustrative radiographs) to help the application of BD.
  
  
  METHODS
  This was an international, multicenter, retrospective study enrolling 221 children [aged greater than 30 days and less than 18 months; median age 6 (range 2-13) months], admitted to seven European pediatric intensive care units (PICU) with acute lung injury (ALI) or ARDS diagnosed with the earlier definition.
  
  
  RESULTS
  Patients were categorized according to the two definitions, as follows: ALI, 36; ARDS, 185 (for the American-European Consensus Conference (AECC) definition); mild, 36; moderate, 97; severe ARDS, 88 (for BD). Mortality (13.9 % for mild ARDS; 11.3 % for moderate ARDS; 25 % for severe ARDS, p = 0.04) and the composite outcome extracorporeal membrane oxygenation (ECMO)/mortality (13.9 % for mild ARDS; 11.3 % for moderate ARDS; 28.4 % for severe ARDS, p < 0.01) were different across the BD classes, whereas they were similar using the previous definition. Mortality [HR 2.7 (95 % CI 1.1-7.1)] and ECMO/mortality [HR 3 (95 % CI 1.1-7.9)] were increased only for the severe ARDS class and remained significant after adjustment for confounding factors. PICU stay was not different across severity classes, irrespective of the definition used. There was significant concordance between raters evaluating radiographs [ICC 0.6 (95 % CI 0.2-0.8)] and risk factors [ICC 0.92 (95 % CI 0.8-0.97)].
  
  
  CONCLUSIONS
  BD validity for children is similar to that already reported in adults and mainly due to the introduction of a "severe ARDS" category. We provided clinical tools to use BD for clinical practice, research, and health services planning in pediatric critical care.
authors.affiliation: Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, University Hospital "Agostino Gemelli", Catholic University of the Sacred Heart, Rome, Italy, daniele.deluca@rm.unicatt.it.
authors.forename: Daniele
authors.initials: D
authors.lastname: De Luca
authors.forename: Marco
authors.initials: M
authors.lastname: Piastra
authors.forename: Giovanna
authors.initials: G
authors.lastname: Chidini
authors.forename: Pierre
authors.initials: P
authors.lastname: Tissieres
authors.forename: Edoardo
authors.initials: E
authors.lastname: Calderini
authors.forename: Sandrine
authors.initials: S
authors.lastname: Essouri
authors.forename: Alberto
authors.initials: A
authors.lastname: Medina Villanueva
authors.forename: Ana
authors.initials: A
authors.lastname: Vivanco Allende
authors.forename: Marti
authors.initials: M
authors.lastname: Pons-Odena
authors.forename: Luis
authors.initials: L
authors.lastname: Perez-Baena
authors.forename: Michael
authors.initials: M
authors.lastname: Hermon
authors.forename: Ascanio
authors.initials: A
authors.lastname: Tridente
authors.forename: Giorgio
authors.initials: G
authors.lastname: Conti
authors.forename: Massimo
authors.initials: M
authors.lastname: Antonelli
authors.forename: Martin
authors.initials: M
authors.lastname: Kneyber
mesh_terms: D055371:Acute Lung Injury / Q000175:diagnosis*; D002648:Child; D032921:Consensus; D015199:Extracorporeal Membrane Oxygenation; D005260:Female; D006801:Humans; D007223:Infant; D015278:Intensive Care Units, Pediatric; D008297:Male; D012127:Respiratory Distress Syndrome, Newborn / Q000145:classification* / Q000175:diagnosis* / Q000401:mortality; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D009626:Terminology as Topic